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tv   Key Capitol Hill Hearings  CSPAN  November 23, 2013 12:00am-2:01am EST

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this matters. i'm out of time so i'm going to run through the last slide or two. and i think the success stories in a lot of states see is if you can treat the rollout of the exchange like a soft opening of a restaurant come and build some functionality in early and then build upon that. that's where we have seen the most success. it isn't always possible but that is certainly something that we have taken away. finally, you know october 1 is important, january is going to be even more important it has been covered to actually start. and we have to make sure the system is ready for them and then finally closing it is the easy part. once you get them in the door that is the easy part. with 72 billion plus people, 400 billion plus dollars a year, all of the sick and the fraley
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and the disabled and the chronic conditions, we have got to do more than just keep them covered, we have got to cover and then at th to the cost curv. david blumenthal at commonwealth has done a famous job explaining this. this is what the states are doing that i think it's is reay exciting news. i'm going to do another session on this. reforming the delivery system and reforming the way that we pay for care in this country. we have to treat health care just like a bunch of economic and the words paying for value that is with medicaid is focused on these days i will stop there and look for questions at the end. thank you. >> that is a great start this
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discussion and now we are going to turn over to daniel skyler who is the director of exchange technology and a former director of the technology for utah health insurance exchange which has been in business as long as anybody. his colleagues have been helping a number of states prepare for the implementation, especially the exchanges and we have asked him to talk about -- we have heard that there are a few challenges in the area of technology, and have asked him to talk a little bit about the challenges and the other challenges that the states are facing in your experience. thank you for being with us. >> i appreciate being here. >> i am going to give you an overview of health reform in utah and talk a little bit about and with the state-based marketplaces are doing and then just sort of try to get some guidanc give some ge
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remaining uncertainties. but, matt said it's the best and i think that it's fair to point out that public changes are the most complex, one of the most complex it projects ever initiated by states and the federal government. and the reason for that is all of the plaintiff integration pon that exchanges need to make. they need to connect with medicaid. they need to connect with the federal data service hub and carriers across the country. with that i will go ahead and give you a little bit of background on what we did in utah. so in 2007 and 2008, utah passed to the any willing language to build a health exchange, which is now known as the avenue age. the impetus was to provide a tool that employers could use to help mitigate the rising cost of health care in utah. one of the ways they did that
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was by establishing the contribution marketplace which would allow the employers to go by their employees with a set dollar amount every month that they could use to go into the exchange and purchase any health plan that was available in the exchange. it provided critics of the become a more options and more administrative cost to the employer and 40 employee to provide more choice, transparency and portability so if they move one job to another they could take their plan with them. it's been very successful. many of you know that utah has default it to the facilitated marketplace for the exchange but they have been given a waiver to run the avenue as the shop exchange in utah. with, what happened? why did we see such a miserable launch on october 1? there are two things that speak to the causation of the failure if you will.
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one of them was the lack of time to build and test. and one of the reasons there was a lack of time is the hhs, cms delay the necessary regulations and guidance to provide the business rules and processes if you will for how in exchange should function or how the subsidies should function or healthy integration should work. all of the nuances with regards to how it should function and it was sort of like trying to build a plane while flying in the air were a race car while it is going around the track. we were trying to develop these rules and regulations and guidance while planning the development and the build of the exchange rate of the administration delayed internal progress and there was no end to end testing rate they tested the components individually but because of the time to the test, that led to the issues that we
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saw october 1. additionally, as the cms and hhs admitted they decided to take on the role and responsibility of managing the project internally. the administration was advised that they should live or -- letter then to one of the largest it projects ever initiated by the federal government and they chose to bring that in and do that on their own. we see what happened on october 1 with a lack of knowledge and to guide a project of the size. there was also a lack of communication between the subcontractors and the general contractors. again this is a part of the overall project management. the subcontractors would express concern about a certain component or certain issue and that would never filter up to those in charge that could take
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the necessary adjustments to the project plan or the necessary adjustments to resolve those issues. so, if we look at the state and what happened with retrospect with, what do the states do differently, and we are seeing more success with the state-based marketplaces. so, i mentioned in my sort of touched on the state leveraging existing technologies. they went out and hired the best practices. they hired a system integrators and project managers to oversee their implementation. they were proactive and innovative instead of waiting for the guidance to come out, they started their guidance project planning early on and started to build and design their exchange without the necessary guidance from hhs. that did require them to make changes as the guidance came out. but because they started early,
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they were able to achieve a level of success that we saw in october 1. the scope was necessary. so they look looked up at the ce fundamentals of the exchange were to start on boarding people. and sort of if you will remove all of the towels and whistles and just focused on developing the core fundamentals of an exchange and they set expectations low. they were proactive in the media and with consumers letting them know that this was going to be a bumpy start on october 1. we aren't going to have all of the bells and whistles. we are going to deploy the core functions that will allow people to enroll and begin the eligibility process. all in all, they took a completely different design philosophy versus the federal government when it came to building the state-based marketplaces and in retrospect if it might have been organized by date might have been appropriate for the
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administration to have collaborated with the states in some respect doping in exchange we might have seen a different outcome on october 1 with but again with, they now have some project management in place through the heavy contractor overseeing the repairs to the platform. we are seeing progress on a day-to-day basis and improvements to the platform. not sure where we will be on november 30. the administration said that on november 30 event 80% of individuals will be able to take the enrollment process and 20% probably will not because the core design issues that still need to be addressed as well as the complexities of the specific eligibility scenarios that matt spoke about. we will have individuals that will have a sporadic residency or citizenship or have never filed an income tax return and
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that will advocate the complexity of determining eligibility for the subsidy before the system can accurately enroll people on a consistent basis but we will just have to see where the platform is on october 1. so, just want to end with federal health reform uncertainties. enrollment plan b. we heard the administration emphasized the carriers int and the web-based entities. there's been a lot of confusion in the media. exactly how that works with respect to the carriers can and cannot do. but i think the administration is making a proactive decision to encourage consumers to use direct enrollment into the concern is that the character moment on the web-based entities is not fully completed you're still working on the technologies to ensure that path works.
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premiums and cancellation fixes the administration announced as to how that is going to work in what will happen to the premiums. will this destabilize the risk pool going forward? and there is a lot of uncertainty what that will do to the premiums and 2014. state-based exchanges. what states thawith states thatg the marketplace were will transition to the state-based marketplace over the next two years. i think in some respects the rollout of will be a catalyst for some states including the partnership to quickly transition and in other states that have been adamantly opposed to the affordable care act this may reenter and then in the position to not build the state-based exchange but we anticipate that many of them will transition over the next two years to the state-based
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marketplace and some, not all, of the federally facilitated barkett place or states that are utilizing the federally facilitated marketplace will transition. last but not least, funding. the federal deficit. what will the funding look like for the ongoing development of exchanges? states have until december 2014 to apply for a draft to build an exchange. the question is will that funding still be there at the end of next year? thank you. >> that's great. thank you. even if you did end with questions instead of answers. we will get to you later with the answer part. >> ms. kaufman is mac stand as the winner of the award for the shortest distance traveled by a local official to get to one of our briefings.
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that is to say she is the director of the dc health benefit exchange authority. in previous lives she has been among other things the superintendent of insurance in maine and the insurance commissioner. today with that, we are here to discuss the experience and dc at the marketplace which is one of a handful being run by the local jurisdictions. thank you so much for taking a cab into coming over. >> you had me there. i thought you were going to say we had the shortest amount of time until october 1. the city didn't sign its contract with the systems integrator until january of this year. so we were the last to the picnic and one of the first out of the gate i'm proud to say. so thank you so much for having me here and i just want to say how important your -- this
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particular session is and how critical the research that the doctor has done on the first 86. it certainly is informative for everyone but especially people on the ground who can then take the research and utilize it to be more strategic in our own outreach and enrollment strategy. thank you very much for your commitment to helping not only policymakers but folks who are on the ground implementing the reform. in the district is really did it take a village and i just want to acknowledge some of my staff members who are here. my deputy and alison nelson. when i came on board in january as the executive director of the health benefit exchange authority, i was the first employees alike off to build my team and i just stole the best people i could find from everywhere the private sector talks people out of retirement
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from the federal government from the hill and from everywhere. i was very fortunate to have a great team help us get to the finish line in helping us succeed. we had to prioritize. we have the core functionality. we took the bells and whistles off the table and focus on the core functionality that we wanted to make sure on octobe october 1. do everything start to finish and we were able to do that october 1.
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they were able to shop, they were able to select the plans. they were able to come and set up their accounts as well so this is just our landing stage i want to make sure that you are aware. we are not the federal site and we are fully functional. we are by the start in fact we have all of the major insurers offering coverage to the individuals and small businesses on the individual site we have aenta, blue coffee and blue shield and kaiser permanente and then for three plus united healthcare. we are very pleased with the fact that all of the carriers are in fact participating.
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for both individual and small-business consumers at all levels of coverage. from bronze to platinum. when a small business comes to us to offer for all that are in the particular level is a small business offers the gold level coverage that means workers can choose. so everyone in the gold level and there are 112 different products. so any of the insurers they can choose from any of the hmos or point of service and the products you can get no deductible plan or you can get a high deductible plan and everything in between.
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i wanted to include a slight on the price since that's been in the news quite a lot. on the individual site you can get a bronze level policy for $124 a month. if you are 55 and you live in the district, you can get a bronze level policy for $295 there are very competitive prices. i want to note that when we posted our prices and adopted
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legislation that requires full transparency in the pricing we solve a real price competition and the proposed rates for fidelity and we made those rates public. one insurance company came back and lowered the rates twice. the proposed rate and another company came back in and lowered their great ones and a third insurer came back in and low birth rate at an additional product. so, in the district we saw price competition work through price transparency. and of course competition greatly benefits individual consumers as well as small-business consumers. we have a lot of activity by the district, lots of shopping any accounts being opened up and lost people picking their plan and requesting the invoice to pay. i am not encouraging anyone to be early because they have until
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december 15 to pay. so i want to make sure that anyone who lives here in the district watching this knows that they have until december 15 to pay. nonetheless, some have paid and doctor collins asked me to share some early statistics with you, and this is -- i had my staff look at the first 120 people who fully enrolled themselves paid getting selected at the plan and paid. so the largest category of enrollment in the first 120. the category of the first 120 enrollment. i think that most of those to those that already paid only
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fully enrolled the levels actually surprise me. i thought that it would be more evenly split in terms of selections. the interesting fact that i would like to share with you is that we have several enrollment age 65 and over. .. and in terms of make a quick
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comment about one of the earlier comments made about hhs and the implementation. i was in state government when the legislation, the affordable care act was being debated, and states had a clear choice. there was a house version, which had one one nationwide exchange and there was a senate version which had each state setting up their own. every one of us, me included, in state government lobbied heavily for state-based opportunities. we argued states can do it better, and we have done it better. and we should do it.y so part of the issue has been so many states who lobbied heavilyu to have the opportunity ny stated heavily to have the opportunities to serve -- set up their own exchange is not to do
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that. and so i think we have to keep that in mind when we set expectations about achievements and opportunity for success when you have the federal government having to set up a marketplace, a very complicated online portal in so many jurisdictions. >> thank you. by the way, your last slide reminded me that if you are tweeting about this topic and this event, there is a hashtag on the title slide, #acamarketplace. did i do that all right? >> you sound very twitter savvy. >> right. our final speaker is katy caldwell. she's the executive director of legacy community health
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services. they are a federally qualified health center in houston that's been working or actively to help his patients with both aca and medicaid enrollment and she's here to share some of their experiences, they being both their patients and legacy itself, with us. we are very happy to have that happen. katy. >> thanthank you, ed and sara. so i'm going to start with just a brief introduction of who legacy is, how we are navigating the system and how our patients are navigating the system, what the interest level that we've seen, what are successes and opportunities have been, and what are our next steps. legacy is a federally qualified health center. we are in southeast texas in both harris county and jefferson county, which is houston and beaumont. we have 11 clinics, and clinical
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locations and seven school-based clinics. our clinics are located in historically a neighborhood, hispanic neighborhoods, an african-american neighborhoods. we are a certified application counselor organization. we have 28 certified application counselors, and we see, this you will see approximately 60,000 individual patients through 200,000 visits. so also i would be remiss if i didn't say texas as i'm sure all of you in this room know, this is not medicaid expansion state, so, therefore, only children, the elderly and disabled are still eligible for medicaid. we are also a, on the federal run exchange we did not object to a state exchange. our marketplace and how people are accessing it, they are coming into our clinic, making appointment or walking in. they meet first with a certified
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application counselor who starts the process by getting them to walk through the consent. this causes a lot of anxiety for some people, and because they've heard a lot of bad publicity. declared about identity theft. there's also been several groups in houston that have been fraudulent groups out collecting information from people, and basically stealing their identity. there's been a lot of publicity around it. we have to get over some of that anxiety. then we have to determine the client's knowledge. and this has been interesting. we need a people didn't really understand insurance but we've had a lot of education around just even the terminology and insurance. the majority of people coming in have never had insurance. a lot of them have low literacy, to begin with, and low health literacy. this group, especially the people have really not, are really uneducated on insurance,
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a bit information overload at this point. many times they leave, they take information and make another appointment to come back. if you have other information with them, we go through their household information, what subsidies they might be eligible for, the different ways you can apply. we get from all their documentation in the design which means applying is the best for them. is the online application or the paper application. one thing that has surprised all of us has been also about a third of the people who have come in have never used a computer. and another third have a computer but have no internet access. and then the of the third, they have a computer and have internet access them so some of our folks are taking time now to help you get e-mail addresses and also connected them with resources in our community where the low-cost internet access and low-cost computers.
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and then we assist them in getting on and getting an application in the marketplace. and then work with them to determine what's the best plan for them. the other part, about half now we are doing and paper application, and this is largely because of the language issues. we are a very diverse community, and online is only available in two languages and we try to do everything in the languages of origin of our clients because they understand things better. there's 11 languages on paper but only to online. and it takes longer to do it on paper because of the length of time of submission. the next part if they haven't had information overload again, which most have by this time, or if they have to submit my paper we ask them to come back with their eligibility. so then it's determining which plan is the best and making the
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application, and this again becomes very complicated especially for any of our clients have chronic illnesses such as hiv, diabetes, congestive heart failure, asthma. because they had to look not only at often times the lowest cost plan on the premium is not the best plan for them. and it's not easy on the federal exchange to go through and compare medications, formularies, to compare what doctors, what hospitals are on different plans. so you have to take all those things into account, and explain what all those things mean to people. eventually though they get through the application process and will choose a plan. so who are we seeing and he was asking? just to our location we've had about 3000 inquiries sense, that we've been tracking since october 1. we've seen about 1300 individual people, most of them, the average number of visits has been three visits with our folks. we completed 89 applications and
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have 18 people go all the way through to enrollment. majority of the people coming in our our existing patients. so that a high level of trust with us and they're the ones that are really getting through the process much quicker than the ones who are coming to us from various outreach events, from finding us on the internet. we're also seeing a very strong mix of age and race across every age that we've been seeing. we have seen quite a few people coming in who are 65 and over. just wondering what this is all about. we end up helping them a lot of times choosing the appropriate medicare part b plan for them. so we're helping on that site also. -- part d. we were surprised how many young families were coming in. host of young families coming in, the children are already on medicaid and the coming in for care for themselves or other family members. so our successes and challenges, so what's working? the system is improving.
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the awareness level is increasing and good publicity, bad publicity made people aware of this is out there, the marketplace is open. so it's about more people in. most people are surprised when they come at how affordable it is. i think there's a preconceived notion by especially people who have sought some of the high-risk pools are people with chronic illness in the past have been unable to really afford it. but as with the d.c. exchange, there are trees prices and people are really surprised that it is affordable. we are doing a lot of advice in a committee. with a couple of organizations that do free and low-cost tax services, filing services for people of low income. so we're doing a lot of that. we are collaborating a lot with other groups and with other nonprofit organizations.
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so what are the barriers or opportunities? trust. trust is a huge issue. again, the majority people who come in do have a lot of skepticism in the system. a lot because of the publicity that there's been. online access in letters he has also been an issue, and learning insurance terms, understand what a co-pay is, what coinsurance is, and just what a premium is. homeland security is very large in our community, and there's lots of people are fearful that while they may be a citizen and ineligible, their people in the household or families who are not citizens and they are hearing from the irs, so it is very real. also hear from other law enforcement. the information will be available to other law enforcement agencies.
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setting up e-mail accounts but lots of people don't have e-mail accounts. that was a big surprise for all of our staff, and also the other issue, inability to compare easily a different plans on system. what are our next steps? were doing a series of town hall meetings to encourage both our patients and people in our neighborhoods to get educated and doing large education sessions. we are setting up in our lobbies of our computers online access for our patients so that they can come in and do some exploration on their own or get comfortable with the computer. we're doing actually some more computer literacy classes, and assistance with that. we are continuing to do all of our outreach and engage potential enrollees. and then we are starting in january going to be doing a lot of health literacy for our patients after of the members in the community. because once again just because
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you have insurance doesn't mean you know how to use it. and what our goal is, at our health center is to make sure that so they get insurance, that doesn't mean to go to the emergency room when they get sick like they've been doing and they are in the habit of doing. but they learn if they have a health care home and how to use the insurance at that health care home. thank you. >> thank you. all right. well, we are into the part of the program where we give you a chance to check out the questions that might have been raised by the presentations you just heard. i would also encourage the panelists if they have heard something they disagree with our want clarification about from one of their colleagues on the panel, they should speak up at any point that they would like to. and, of course, sara is in a position to ask very informed questions.
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if you did go to the microphone i would ask that you identify yourself and try to keep your question as brief as you can so that we can get to as many of the questions as we can. and you had the honor of the first question. >> thank you. bernadette with congressional resource services. i a couple of researcher question. the first one to my love. your initial -- mila. gravitate to plan is a question about what you to be the to? are these folks uninsured with pent-up demand, are the kind of tied with the over 65 but maybe just are looking for more generous coverage? that's my question to you. and into the broader group, kind of looking forward beyond broad david and premiums, is there any plan to put additional information out there such as enrollment by demographic
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categories as well as additional plan features like cost-sharing requirements? >> thank you. so i wish i knew, is the short answer. and i should caveat all the initial numbers i gave you by saying, i don't think it's a prediction of anything. it's just looking at the first 120 period. i think it's interesting that pretty much every age category is represented. including the younger population, of course, enrollment you want to make sure that you are targeting everyone and you have a healthy risk mix. and i do not know anything about the short status of enrollees. we actually, unfortunate, did not bill that data element into our application so we are not collecting it. we do plan to do a survey in
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2014 of all of the enrollees to ask them whether they were previously insured and what kind of coverage they had. and we do have plans to closely examine our data, probably early to mid-next year, once all of the dust settles and we have good data to look at. and we will be making all of our information, the demographics, enrollment statistics all public once we have good data to share. >> have others on the panel experienced the same sort of platinum coated enrollment phenomenon that milo was describing? >> many of ours have been silver vessel we are seeing. but we don't have 18. [laughter] >> not a representative sample by any means.
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>> also on the data availability, i think that's a really excellent question and really i don't is looking at this carefully wants to know who is enrolling. the caldwell fund will review our survey that we did in october in december just to get another snapshot of what's happening in the marketplace. hopefully we'll have a little more sample so we can have a better idea at least in a very broad way of who was coming in, and then go in at the end of the open enrollment period again with a little bit larger sample. in terms of a national data that will be available, national health interview survey data i think will be the first national look at, at least at a broad individual market level perspective available starting in september. we will know what the first quarter coverage look-alike in this year. so i think the state reports, my
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list report just now is so important, so interesting and in california, other states that are recording, demographics this division are going to be really important to understanding what's happening. >> all right. go right ahead. >> i'm a legal intern at hhs. i've a question that's mostly directed for katy caldwell spin could you step on little closer to the microphone and? >> canyon me now? wow. i'm illegal internet hhs. my question is directed to katy caldwell. how is your health center responding when you encounter people who fall below 133% of the poverty level? and also, do you help people realize if they're eligible for subsidies? >> on the subsidy question, yes,
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we do help people determine whether subsidies are. that's the easy one. the hard-won is telling people they're too poor to get a subsidy. and it is difficult and we haven't people coming in now looking at that, that i fall into that category. if we had expanded medicaid they would be eligible. so we're talking to them about just when we do, whic which is e your options if you come here to care, we do everything on a sliding scale. we will help you in any way that we can, but it's still using our grant funds and other funding that we have to help care for them. and what our goal was then is to educate them again like we do it all of our patient, try to keep people out of the emergency room and keep it in routine care. >> and just to put a data point on that, too, the size of that
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coverage gap population, kaisers number is right about 1 million people in texas. so that's a considerable number of people your. >> hi. my question is for mila. are you concerned that there's over 100 plans to choose from, people will be overwhelmed by the choice, or they would just choose based on price? it was a problem for part d. it's still a problem for part d. people are reluctant to go back in and make another choice. and i think kaiser has shown that they don't make the best choices? >> thank you for the opportune to clarify. so, on the individual side we have 34 products. 31 our meta- levels, and three are catastrophic. so on individual side there are fewer options, fewer choices.
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on the smoker decide, on the shop side, 267 different products. we know from experience that small businesses themselves are like a choices. if a $15 co-pay is right for one small business, another small business wants a $20 co-pay. so we know that from the massachusetts connector experience in small group market and we know that based on the commercial side of the market. and i have a private board that made many of these decisions with a lot of input from policy stakeholder workgroups. so we decided early on that we wanted, that we didn't want to limit products. we wanted carriers to be as innovative as they wanted to be. the one early decision that we made, which was unanimously recommended by all stakeholders including consumer groups, providers and carriers was that
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we would not allow benefits substitutions to the central health benefits package. and so that products could have additional benefits like acupuncture as an example, if not one of the core benefits. so the variation in product is really additional benefits on top of the essential health benefits benchmarked and the variation in your out of pocket liability. so the co-pay, coinsurance, et cetera. >> thank you. spent thank you. i also work in coalition with many asian-american organizations. so my question has to do with the language barrier. have you seen the problem cents we have not only on paper? you said 11 languages on paper and only two languages online for the application. so does that pose any problems?
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in virginia, we have a high percentage of asian americans in virginia and its rising but virginia still not choosing the american expansion decks i don't know if you have any number from, from the federal site. how many asian americans coming in and giving problems about it is anything that you think the committee should step up and work with you? because as i understand we'll have two mitigating in virginia. and with tremendous amount of asian americans, small businesses and many of us are not inhabit at that insurance. i can talk from texas. it is a problem we have the largest been in thi in these coe in the country in houston, and we are pushing to get the third
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language to vietnamese for us. and, but it is a problem and we're just glad that there are at least 11 languages and we run across people that it is not that we don't have the appropriate language. in those documents. it is an issue. because it is much easier for people to understand in the language of origin and so we are working with everyone to try to get better access. but yes, the answer is yes, it is a big barrier. >> so in the district our biggest immigrant population is spanish-speaking, and the next largest is ethiopian community. and then we have also a nation population. for asian and pacific islanders we a partner with our mayors office, and our partners are essentially doing on the
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groundwork. we found with working with different culturally different groups, that having a working online portal is not relevant, and that many people, many immigrant communities, small business owners and individuals really like the one in one interaction with a trusted voice. so we actually have focused a lot of resources into the on the ground people in the community who can work one on one with a small businesses and individuals, with all of our the first populations. >> what kind of relationship do you have with the insurance brokers in the district? >> so, from my perspective,
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excellent. we actually have the brokers involved very early and we build a broker portal. so there's a consumer portal and there's a separate broker portal that's designed to help it, help make it easier for brokers to place business to shop at. we have very good feedback from brokers and, in fact, we're doing some enhancements to our portal based on some feedback from not only consumers but brokers using the portal. the other point i just want to add, we also partnered in a formal way with the national association of health underwriters and they did all of our broker training. which also helped a lot. we also have partnership with all of the, most of the business associations like the d.c. chamber of commerce, the restaurant association and the hispanic chamber in d.c. and that is held a whole lot in terms of not only educating people about the affordable care
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act and all of the opportunities, and also being trusted messengers, and now those business partnerships, they are helping us with enrollment as well. >> him david helms. more to this discussion, i led the robert wood johnson's health care for the uninsured program when we tested voluntary subsidized products for the working uninsured, and i am interested, mila, and those who have had a chance to look at the plans, the "washington post" of course discovered that maybe some of these plans will have to have narrower networks that may exist in the rest of the market. and i would report that there are no easy ways to make health insurance affordable. and we tested a lot of these from purchasing cooperatives to subsidies, the narrower networks. and from those early projects
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reported in health affairs in mending the flaws in the small group market, note that the uninsured were not unwilling to use narrower networks. they wanted the range of care from hospitals and ambulatory and so forth, but i just wondered if you were hearing any or seeing any evidence that looks like this will be the next issue people want, not everybody's going to get him the same choice of health providers maybe they had before. >> i can say that in the district, the products that are being offered are very much, in terms of the provider networks are very much the same as currently in the commercial space. and so about half of the products offer nationwide networks. and the other half very robust local and regional provider networks.
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i don't think there's a single product that was filed to be filtered that has what we would consider a narrow network. >> i might add that i would say that from a macro perspective, narrow network company, it connotes different things. it doesn't necessarily mean bad quality. there's a lot of providers out there. i don't know that we want to be with. and i think it is an inexorable move in the insurance industry in this country towards narrower networks. selective contracts. obviously, ideally you want to do that so you've got a high quality low cost providers within that. but let's not try to pretend that's necessarily a bad thing. >> and i would refer you to the briefing we did last week on reference pricing for a number of private sector entities were
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moving in that direction in a very large-scale. >> i believe you were next. >> hi. hello? does this work? on monica from gao's office of general counsel, and one of my practices is and how flaky an aa question for dan and mila about the bells and whistles you refer to -- >> get a bit closer to the microphone. >> sorry about that. those of you refer to bells and whistles in the cms federal system and you pointed out that one of the things that led to the successful design and implementation of the csm or the other state systems we scope and requirements and to cut out the bells and whistles. in comparing that to the federal system that has to interact with the hub and the carriers and make that, make the decisions for the applicant come what are some things you can scope out? >> like what are the bells and whistles? >> so just for the record i did not say we scoped out anything.
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we actually write should be. so we still intend to do everything that we plan. we just couldn't do it before october 1. so it's just been right shifted to 2014 and perhaps a few years but it's things like the provider network. ideally we would have a button, a consumer could click on and have access to the carriers network right there. we couldn't build in the provider network feature into the portal, and so what happens now is a consumer has to click several times. and actually from our site, click into the carriers aside and go straight into the provider network that they carrier maintains in their website. so that's an example of a bell and whistle that we just could not do. for october 1 launch. we plan to do and we will do.
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it's just going to be sometime in 2014. >> my name is dan brown. i'm with the american occupational association. the lowest cost option is not always the best option for consumers. katy mentioned it's difficult to access information about provider networks and drug formularies. we've also found that is difficult to access information about coverage services, unlike in d.c., and most a substitution of benefits is allowed even if the consumer is aware of this benchmark plan and those was covered by that plan. there could be variation in the marketplace. i'm wondering with all the i.t. problems and enrollment challenges if d.c. or other state run exchange is are actually looking at the consumer experience making sure that all the information that ideally
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would be available for consumers to make informed choices is available? and a related issue that is accurate, we found some information that's available on the marketplace interface that is not the same as the summaries of benefits and coverage for the plan. so i'm wondering if any state run marketplaces are looking at the availability of that information and the accuracy of that information? thank you. >> yes, yes, yes and yes. so we found early on that it was very difficult to find the formularies, and so we worked with the carriers to make that more prominent and easier to find. but again, that formula is not going to be in our portal until next year so consumers still have to get a few clicks to get to the formulary.
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the consumer experience, so let me just say, the most important part of all of this is the consumer expected because if the consumer has a bad experience, then it's hard to convince the consumer to sign up, get coverage. so we are very interested in consumer feedback. any feedback we get, whether it's constructively phrase or not we take seriously. and we have a long list of improvements and add-ons we plan to make to improve the consumer expense. we do updates to our system on a regular basis to add in enhanced features to help with the consumer experience. in terms of the contradictions and information with us benefits and coverage and what the plans
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actually cover, just like we build a portal for brokers, early on we built a portal for carriers. and so this summer carriers have to load all the rates in the plans and we did significant back and forth testing with the carriers so the carriers would come in to their portal to check everything out to make sure that the summit of benefits in coverage actually matches the plan that was approved for sale and there were no discrepancies. and that's how we are able to address some of the discrepancies that the plans and identified early on. so hopefully a consumer shopping in d.c. does not find any discrepancy and if they do i want that call personally so we can address that. but i just want to invite think the consumer experience in improving the user experience is critical to me.
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>> office of personnel management. the federal employees health benefit program. i have two questions actually. first one is for mr. simon but i hope i pronounced that correctly. on the medicaid expansion, with large font of soldiers coming home, how these offerings for that large population transitioning even though their state may or may not be offering it because the job may or may not be there. income is cooler. how are we setting buffers? and the other question is for the state. excess of health care now we have that. what are states proposing to deal on the clinical provider side so that we can provide services for those people? >> that's a great question. on returning soldiers, returning veterans. i confess, i'm not sure.
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this is not traditionally a job that medicaid takes on to try to look at. i think the court of the issue you're getting at is employment opportunities for returning veterans and i think it's a really, really important issue. i know a lot of states pay a lot of attention on the. that's not something that we focus on. so i can address that. but to the extent that there are issues there that we will take a look at that and we can get back to you. >> matt, you have one of aspect of the gentleman second question about the adequacy of the provider networks being one of the other question cards that we have up here. someone was wondering whether there is any state that has decided to hang on to the primary care increments in medicaid that was included for the limited time at federal
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expense in the aca. >> so i guess the question there is, because when the things the aca did was that the increased medicaid payment rates to primary care doctors to the medicare level. which is great. but it did so for two years and then some said it. and, in fact, it was intentional -- it was intended to improve access although the first year that went into effect which i to 2013 for the expansion started and it is at the end of 2014. which i think is a terribly cynical wit about going federal polls. the framers of the law assumed a future congress would come in and extend it and would have and medicaid doc fix just like we had so much success with the medicare doc fix for ever now. i think it's way too premature to say what are we going to do
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when that goes away because i think this is very much in congress is core to figure out, do they want that to just go away and in what will that get access? i think that's a question for congress and not for us. we not going to try to answer that at this point. >> i have a question for matt and a question for mila if i can. i want to ask met come in your snapshot you said you think medicaid data may be taking a want to get a better sense of that. are using different people enroll now and you saw previously? given that the enrollment data has not been, didn't come it's been delayed because of account transfer problems, are you concerned about how solid hhs data might be? you expressed some concerns that some people who enroll or people who applied were i could already enrolled in medicaid. so how solid is the hhs data,
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and for mila, i'm wondering, something people here might be carries about is, do you envision any way at all people who have been assigned to go to help link to be able to go back if they want? >> so, to the first question, in terms of the data and you're right, the inability to actually do account transfers is not yet fully functional. it will come. not sure win. i don't know that's a catastrophe. i don't know that's a crisis. the issue i think you're getting at a ransom the data which is also the batch files that are common across, it's really more of a system hhs of here's who we think will be coming to you. and here's some information about this so that states can kind of better prepare some of the workload, do we need to staff up a call center?
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you know, and yet, so we've seen some challenges there. you know, there's a lot of challenges with everybody's data at the onset, so i'm not care but concerned about any of that. it will get cleaned up. it's not going to be huge problem i don't think. >> yeah, i would just refer you to a pm. as you know, the affordable care act has a provision that says that certain designated staff and members can get or have to get their coverage through the exchanges. and the final rule that opm issued as a source for qualified coverage that is eligible for the employer contribution. so i welcome all congressional staff and all members and look forward to serving each and
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everyone. >> yes, go right ahead. >> hello. i'm with the national association of social workers. my first question is both on a micro and macro level for katy and matt. are either of the agency level or at the association level collecting data about the turn away rate in the not expansion state? katy, you mentioned there about 3000 inquiries after clinic in the last two months. if there's any data as to how many of those were people below the poverty line, who could not get coverage because you're in a not expansion state. >> we are collecting that. i don't know the number of the top of my head but we are clucking and we are seeing quite a few. and we know that we're going to be seeing a lot more. we are an hiv service provider and we have about 4000 hiv patients, and we know just by our data that about 1500 of
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those patients will not qualify. would qualify for medicaid expansion but not the other. but we are tracking it. the short answer is yes, we are tracking it. spent the at -- and the short answer is no. we are not talking. we represent the medicaid directors. we've got a third of our staff here today. you know, we try to prioritize, providing information to the members to help them better implement, so the snapshots we've been doing is really to help level set, to help states figure out are you struck him with this issue or that issue? are you the on one or is anyone struggling with that? so we don't have the capacity to dig down and really, really be a data warehouse for everything like that, unfortunately. >> thank you. >> someone else have a question related to the. wanted to know if states that were using alternatives to the traditional or the medicaid
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expansion under the law, whether the states might see differences is enrollment. different approach. >> i don't know that we've seen much in terms of different enroll a. at this point we're really only talking about arkansas at this point. when the aca had the medicaid expansion and then the roberts supreme court declared it unconstitutional, it turned to medicaid expansion into a state option. as your slides appointed a, but have the state said yes, about half said no. in large part because largely guilty choice they had was yes or no. then we had arkansas come along, very, very interesting singer we have a democratic governor and the very conservative republican legislature and governor bp went to secretary sebelius and said, i need to do the expansion. i can't get it through if it's just medicaid. let's figure out a third way.
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and together they worked out a plan to essentially expand medicaid but to take the vast majority of those individuals essentially and roll them by the exchanges, via the marketplace. through premiums of technique called premium support. at this point arkansas is really the only state that's been approved to do that. and i think what they are going to see is, you know, you're going to see by definition the figure, frailer, the more disabled individuals as part of the expansion will be in medicaid. the younger, healthier, and better health risks for the pool will end up in the exchange, and quite by contention according to their calculation, their proposal, that in and of itself is going to sustain and save the exchange markets by having that bolus if you of younger,
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healthier lives in that pool. i think you're going to see a lot of folks in there. >> i guess this is actually a sort of same question and i was going to address to you. i just wanted to know, if you be seeing more states who have opted out of the medicare expansion who will be using that model. i think wisconsin is using that same model. i think i heard that it's going to take off this enrolled people off of medicare and put them on exchanges and then to make way for new enrollees to i guess i just wanted to your whether or not there are some downside our upside to using that kind of model. and you think other states are going to do the same? >> so, in terms of medicaid, i would say the wisconsin issues different. wisconsin, it's funny, the wisconsin folks say why do we keep getting labeled as a non-expansion state?
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we expanded a decade ago. they already cover all of these people are and so it's, i think the wisconsin situation is very, very different. but i think it's a very, very silly question to talk about, what does arkansas mean for -- salient question, for the other states that are currently either leaning know or are at no. and i think, i know for sure that the vast majority of states who are currently in the no category are i would call them in, they are in the know, but looking for a way to get to yes. and what it is they look at the options that they have. in the options they have are expand the program as is or nothing. they keep coming back and saying, there's got to be something more on this. it's got to be another option. arkansas has got one. is there another option for us?
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and i think would at the end of the day it's all about whether or not those individual states because of you all ask for slightly different things, pennsylvania and michigan and iowa, they are all asking for slightly different things. it's really going to come down to is the administration going to be willing to work with them to come up with a fourth option, if this option, a way to get there? i think the arkansas model, was the conservative flavor of the private sector approach, and as a way strengthen the exchange market the potential to be a big win-win for everybody if the cards so of on. >> this also raises the question that dan brought up earlier about the states on the exchanges also on the marketplaces who are doing plan management, there are about 14 states that are doing a little bit more than just, than some of
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the other states. whether we will see a shift in that responsibility, taking on more of, states taking on actually the market place operations. maybe talk about that. >> allowing states to transition from a partnership model or a fully federally-facilitated marketplace over the next two years. states were anticipating filing a blueprint on november 18 that, the states that were interested in doing that transition and we'll have to see how many states actually filed a transition blueprint. but they have until the end of 2014 to make that decision. so again, we think there's a lot of into this for many if not all the partnership states to transition over the next two years, and some of the ethics in states that will just have to keep an eye on the state and see which ones do.
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-- ffm states. spent as we going to last 10 minutes or so, i would like to ask you to pull out the blue evaluation forms and fill them out as we get to these last few questions. i would like to ask you to ask your question. >> hi. i've got to question. the first one is just about the enrollment data that's been released in terms of young people, so maybe sara and mila you guys can answer this. is that data on target as far? does it represent a lot of work left to be done, or is a good sign? and then secondly, how is that data in forming study specifically for reaching out to that group? mila, you were talking about data is simple to adjust outreach strategy. what is the data telling you this far in terms of what's working and what needs to be done? either going to be specific things to sort of try to bring in those procrastinators that it been talked about?
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>> just in terms of the data that's coming in, i think this week we saw in states that are going to own marketplaces that are reporting it, significant shares of young adults, about 20% of those who enroll were ages, 19-35, in terms of what cbo is projecting, of the seven many people expected to come into the marketplaces next year, about 2.5 million or so are expected to be with, between the ages of 19-35. so about 30% of that total. in our survey data in october, we did see about 21% of those people who visited the marketplaces and these are people who are uninsured or eligible to come in were 19-29. about 32% were 19-34. we also found a high percentage of young adults, and there was
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really no difference across the age groups in terms of people who say they're going to come back to the marketplaces or go to the marketplaces like the end of the open enrollment period. and just in terms of the massachusetts experience, young adults have waited somewhat longer but the uninsured rates among young adults is 21% in the year prior to the passage of the law in massachusetts. that rate dropped to 8% in the after. i think it does, the experience, the survey research that we've done, the experience in massachusetts does suggest young adults will come into the market places, the numbers will help do what we're hoping they would do not only helping them but also stabilizing the market. spent so, we used all sorts of information sources to, on a weekly basis, hit the restart button. i had a meeting with my senior folks every week, looking back
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at what we know about enrollment, what we know about folks who were on the ground. so if we know that holding an event in the evening results in five people showing up versus launch, you get 50 people to show up, that's where our resources go. so we look at everything that's happened to not only the data we're seeing but also what we're hearing from our sisters. orienteering from brokers in community groups or on the ground. end of the week we slightly shift our strategy. and i can tell you week one at a lot of events planned, educational events and what i would call show until comic indication people have a fancy term for it. but essential have to use our web portal, the range of prices, products. we found that consumers are coming and ready to enroll. so the following week we make sure we had a assisters and brokers at those events to help people enroll. so we learned a lot about the
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needs and demands every week, and we we tool to make sure that we are right there and available to help people whatever they are in their decision-making process. >> so are there any specific strategies to reach out to young people? >> it's a big outreach program for things that are yet to be unveiled. so some of our d.c. assist including young invisibles and groups who have worked with university population. and they're doing very creative things. one of our d.c. alpha link assisters is going to bars to provide information. so they're very creative are and the one thing that we're not doing is kind of door-to-door or going into people's homes. we have essentially said for a number of reasons were not going
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to allow assisters to do that. but they can be as creative as possible and ask our daily and weekly updates. and we share that among the assisters. what's worked, what hasn't worked as well and how to retool. spent can ask just one last thing? just i think a few minute ago we learned that deadline to sign up for coverage for january 1 is actually been moved back a week to december 23. and i was just wondering if it has an effect on what any of you guys are doing or will have any kind of ripple effect in general. >> no. we are pushing for december 15 to enroll in fully paid for coverage to be effective january 1. >> we have time for just a couple more questions. and one is directed specifically
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to you. your mention of the direct enrollment option, that is direct by plans, the questioner wonders whether that raises technology issues firstly? and what potential with this option ever increasing enrollment? >> that's a great question. i don't think hhs ever intended for health care that got to be the single channel for enrollment. and they don't think they ever anticipated they would be the single channel for enrollment in 30 plus states. so there's a provision in the law that allows carriers and web brokers like e-health and get insured and others to direct enroll consumers directly from their platform into the exchange. and when i said to enroll, enroll in a plan that the carrier is offered or a plan that the web broker is offering. there's been a lot of confusion
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in the media about this since the president sort of announced direct enrollment has been obscure and has been a lot of information about it. so really how it works and hhs is providing the technology to the federally-facilitated marketplace states and these technologies are called apis, and allow the carriers and the web brokers to plug into the ffm and to direct enroll. there's been some confusion and misrepresentation in the media saying you can't do that because the only way to get a premium subsidy is directly through you can get a premium subsidy through direct enrollment if the technologies allow the. somebody would go to a carriers website or web brokers website, they would take a plan and then you would be securely transferred to the federally-facilitated marketplace, or a state-based exchange, to calculate your premium subsidy.
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you would then be taken back to the carriers website or the web brokers website to complete your enrollment and the plan that you have chosen. as of today, only carriers that are working directly with the federally-facilitated marketplace or can do direct enrollment. and while those technologies have finally been completed, they were supposed to go online october 1 but there were a lot of issues just like they were with on october 1. a lot of the carriers and web brokers are still trying to complete the final integration to make that work. i'm not aware of any state-based exchanges, and mila, correct me if i'm wrong that are facilitated direct enrollment this year but i know that there are some that intend to do that next year. but to answer the question i think it was the intention of hhs to provide multiple channels to consumers to enroll with state-based exchanges,
1:20 am and through direct enrollment. it's a little plate in the game to speculate on how well directed moment is going to work considering the technology wasn't completed until just a couple days ago. and again, many of the direct in rowley's are still working on integration issues here. >> any final observations by any of our panelists? sara? >> i just wanted to add one more thing for people have been concerned about consumers in this process of direct enrollment. health plans have to let people know that there are other options available to them on the marketplace sites, and also about the other range of products, other health plans that the insurer might offer. but clearly this is a way that enrollment might increase over the next few weeks to get towards the end, not that december 23 date. >> that's correct. they need to inform the consumers there are other
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options on the state exchange and they can opt out of direct enrollment anytime they want to go directly to the state exchange, or the federally-facilitated marketplace if they so desire. >> i just would like to make a plug for tomorrow. we have a citywide enrollment event at mlk library. we're going to have zumba and health screenings and bring your whole family and i encourage all of you to come out. >> okay. well, what an appropriate way to come to the conclusion of this discussion. we may come back to this topic sometime in the near future, in case there might be a few remaining issues we haven't quite tied up in neat bundles yet. but at this point i think we've learned an awful lot, at least i have, and reminding you as we finish up to hand in the blue evaluation forms after you filled them out if you would. i want to thank our colleagues
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at the commonwealth funds for their help in planning and, obviously, making a big direct contribution to the success of this briefing. thank you for some of the best, hard and microphone questions that we've had in a long time. and ask you to join me in thanking the panel for a really enlightening session. [applause] ..
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[inaudible conversations] . and author francis rooney, ambassador to the holy see, looks at the catholic church and its role in global politics. plus your e-mails and phone calls and tweets. light at 7:00 a.m. on c-span.
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>> we have the health care rollout of data have the health care rollout update in this and 16 minutes. >> i think that if i had to say the one thing that didn't happen, and i have said this before, they said that they understood it is a really good health side, especially health insurance.
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>> you don't give this to just anyone, not to see him ask him and this isn't in there realm of things that they can deal. >> the real issue is that they have to get the exchange is up and running.
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>> and that would be would be nowhere near that yet. >> correct. >> i think that this is encouraging and disappointing. >> that is not a complicated thing to do.
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and less than a day, to actually be easily searched and done and it cost less than $2000 to do this. and this is not high-level complex computer science, we know that this problem can be solved. and that was part of the easy part. and again, that is. >> that they may not today, 106,000 enrolled in october and just over 27,000 through the
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federal website. and that is not what was hopeful. >> how far does this set the affordable care act behind in terms of ramping up to its goal or anywhere near its goal. >> we all know that people.
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>> you have no pr, basically around. i think that it's very difficult to extrapolate these numbers this is a long play, this is a play that will transform the american health care system over the next 20 or 30 years. and i am very confident that over a year or two we are going to get this website perfect.
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and that will put unremitting downward pressure on the health care system to become much more efficient and focused on patients and that will be a very good thing. >> okay, so president clinton said that he believed the administration should honor its commitment to let people keep health insurance that they have and senate democrats and feinstein from i believe today, they have joined in the call for some sort of fix that allows people to keep their insurance plans that they would be able to about 20 times. >> okay, so let me be clear, my
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view is in the minority. >> before obamacare, constantly changing plans, raising the rates and excluding coverage and this is not a new practice by them. they do not see this individual market as a long-term back. they are not going to be out of that market and into the exchange for the future. so they have other reasons, it is easy for them to blame obamacare. i believe that we kept the president's promise because we grandfathered every plan that is
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the insurance company for their own business reasons. and i think we honor that. and president clinton didn't. and it's clear that many american people and the american public thought that it was different. it would not even rank. and they are feeling of loss. and here's what i can imagine. i don't think that the proposal, anyone, that's not what the president said.
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in the old system had this exclusion except as i mentioned, the more liberal in the regulations about what constituted this plan. >> that would help balance the ratio and right now annoyed is winning. and so there is no doubt about it. >> let's talk about and where
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they are and that sort of thing. >> as i understand it, it's not 100% perfect, but i also think that this is something that is not urgent on this minute because you have to get that information to them in a timely manner, but you don't have to do a database or collecting the number of people that they don't need six weeks. and i think the point is not that complicated. and i have talked to some i.t. people as to why this has been a complex program for the people.
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that makes you believe that it is a solvable problem and it will be solved. >> putting on your visionary hat for a moment. let's assume that the website gets fixed and we all know that the affordable care act is the long it's going to be the law and so it's going to have some time to start this transformation that you talked about at the beginning. and so it can so how it affects you and me, especially as we get older and we get the point where we will need the current system that we will have this end-of-life care. >> you have given me a minute and 40 seconds to answer what is the most important question. [applause]
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>> the first thing is from an insurance buying standpoint, i think more of us are going to be in the plan and that is for us and i do believe less and less than a will get it through her employer or other means. and i think that's a good thing. we will be able to figure out what is best for us we will see more of this go out of the hospital it will be linked electronically so that if you get eight test, your pediatrician will have it and you'll be able to get antibiotics and convenience will go up. the really important transformation, i believe that is beginning now and will blossom towards the end of the decade is a lot more vip care, focused on patients who have chronic illness. patients who have that,
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diabetes, cancer, asthma, copd, they are the people who actually use the health care system and cost a lot of money and we have not done well in our situation with these chronic conditions. and we are now going to focus a lot more on these people. trying to prevent them from getting sick and having exacerbations of their problems and we will have visiting nurses going to their house and it will be an era in and around the houses built in to their scales and what they eat and the medicines they take to make sure that they are doing well and things are just beginning to have someone go out of the house and intervene, i think that is concierge care or high-tech care that will be the wave of the future. for the rest of us from a lot
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more convenient. >> smarmily see the results and how are we going to measure this. are we going to see life expectancy go up? are we going to measure this? >> closer to those numbers. what you will end up seeing by the end of the decade is and those are going to be the metrics. >> okay, we will look at it. they do so much. >> here's a look at our schedule. next, remarks from wisconsin governor scott walker on a run for the presidency in 2016 in the current gridlock in washington. and then a look at the u.s.
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financial system of years after the market crash for the middle class. after that, the alliance for health reform holding health insurance exchanges. >> i thought it was fun to have a view of history from a timely america that wasn't instructional that was a little bit more anecdotal than actually more archaeological, meeting random. you see bunches of weird photos and captions and explaining them and i had a vision of high school students living history. >> the big picture, sunday night at 8:00 p.m. at q&a.
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>> you're watching c-span2 at politics and public affairs featuring live coverage of the u.s. senate. watch key public policy events and every weekend the latest nonfiction authors and books on books on booktv agency has programs in our schedules on her a website and you can join in the conversation on social media websites. >> earlier today, scott walker spoke at spoken about this held by the christian science monitor and he spoke of a run for the presidency in 2016 in the current gridlock in washington. this is one hour. [inaudible conversations]
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>> welcome to another of our gatherings and this morning is governor scott walker and this was in june of 2012. live conveniently in iowa and then moved through wisconsin he was 10 years old. tied to tiger's dad works as a baptist preacher. and that included spending cuts and returning part of the paycheck for the county. elected wisconsin's governor in 2010 and in june 2012, he became the first u.s. governor to keep
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this in a recall election and it was triggered by his efforts of collective bargaining rights and he has written about that experience and his in his new book that they paid me more, unintimidated. there is no embargo except our friends at c-span. except that our friends at c-span agreed not to air video of the session until one hour after the breakfast is over to give this.
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>> i will dedicate the time to taking questions. people in my state and around the country ask to learn more than they knew about the protests probably most
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importantly is the why. many people don't know why we did what we do and why do the forms look even better today and not as that is the focal point of this book. let me point out throughout this week that people are looking for a particular book, and it is a little bit as far as our prior experiences as account executives. and they can come from some other group of supporters and
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everyone here in our state, and they reduce the difference and they can give people like me that local officials who deal with that. she essentially said no. that was one of the most difficult things i went through and a key part of i wanted to make sure that if any changes and more importantly, we have
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lowered taxes and we have been able to make investments in the last budget and education.
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>> going over to craig guilder. >> he said the employee pay with a big part of wisconsin's budget and this includes health care and pensions and we have big bold solutions being a part of that. includes a the state level for these different kinds of problems. >> they are different at the federal level.
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>> holding back on this collective bargaining, that means many of our districts have been that we have enacted that one change. there are different sorts of issues and there is more than half of the budget. anything we did, the budget has massive tax increases.
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many reforms have been discussing things that don't happen to current beneficiaries. in our case, we have this to pay off the balance of the budget making a convincing argument. >> as far as it goes, moderate term friend. definitely moderate and policy.
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michigan, ohio, pennsylvania, and new mexico, all those states are states that have republican governors. many of them have republican governors. they are probably more conservative.
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>> this is a more political version. >> governors like to contact us.
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>> everything switched from democrat controlled republican control.
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and that is why we need to focus on the 2014 election, to make this case to help the senate a candidate for being the majority the united states senate and then i think the future make a convincing case to the american public get this party a chance to show what we can do. to show that we have been affected in terms of the economy and the fiscal issues and as a translator. >> okay, that sounds good.
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>> so basically republicans want divided government and i can see that that is not necessarily a good thing. as we did in wisconsin, we need to case. the people in our states. >> and then here are the things
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that we bless our congressional candidates sweat. i probably would've said that the name would be finished and everything scares about it. because i was the kind of focus and they said, we are just a little bit different. and the people who are in power before.
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>> you actually gain this last november as the head of the ticket. the governor is elected in 1975.
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>> especially those with the aggressive entitlement reform in the country. you cannot get food stamps unless you're working or enrolled into a training program. they want to make it easier for people to get work and so we are doing now. we don't have education. talked about in the book as well. we have performed traditional schools and we expanded the school choice across the state of wisconsin and we have brought them the opportunity of
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homeschools. we've taken on this reform. there is a chapter on lazio. we have talked about things. >> this includes a college degree. and this is not having to be something that you mentioned
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before. >> or do you think would make the best president and why? >> includes a current individual, just because they have more importantly part of this across america that people want as part of that. this includes looking beyond a congressman's point of view. i advocated strongly for him to
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be on the ticket because he has this unique skills and characteristics. i have said that makes a lot of sense historically.


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